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Abstract:

Described herein are compounds (including medical foods, pharmaceutical
compositions, methods of compounding them), methods and systems for the
diagnosis and/or treatment of prodromal schizophrenia. For example,
described herein are methods of treating a developmentally-based
neuropsychiatric disorder (schizophrenia) that includes first determining
if a subject is at risk for such a disorder by examining phenotypical,
serological immune markers and genotypical biomarkers. The biomarkers may
be used to tailor the dose to be delivered by the medial food or
pharmaceutical composition. Also described are compounds for treating
prodromal (rather than full-blown) schizophrenia.

Claims:

1. A composition labeled for treatment of prodromal schizophrenia, the
composition comprising an agent that restores the function of the
blood-brain barrier.

2. The composition of claim 1, wherein the agent that restores the
function of the blood-brain barrier comprises an inhibitor of MMP-9.

3. The composition of claim 1, wherein the agent that restores the
function of the blood-brain barrier comprises one or more of:
doxycycline, minocycline, and valproic acid.

4. The composition of claim 1, further comprising an N-acetyl cysteine
(NAC) compound.

5. The composition of claim 1, further comprising a lithium compound.

6. The composition of claim 1, further comprising an essential fatty
acid.

7. A composition for treating prodromal schizophrenia, the composition
comprising: an N-acetyl cysteine (NAC) compound in a first amount by
weight; a lithium compound; a fatty acid compound.

8. The composition of claim 7, wherein the concentration of the lithium
compound is approximately 1 mg/kg.

9. The composition of claim 7, wherein the fatty acid compound is between
about 1 and 0.1 percent of the first amount.

11. The composition of claim 7, wherein the composition is compounded as
a single dose.

12. A method of determining if a subject is experiencing prodromal
schizophrenia, the method comprising: determining if the subject has a
genetic susceptibility to schizophrenia; determining if the subject's
blood brain barrier is compromised; and indicating a likelihood of
prodromal schizophrenia based on the presence of a genetic susceptibility
for schizophrenia and the compromised status of the blood brain barrier.

13. The method of claim 12, wherein determining if the subject's blood
brain barrier is compromised comprises determining the subject's
expression or level of one or more of: TNF, IL-1, IL-6, Haptoglobin,
MMP-9, S100B.

14. The method of claim 12, wherein determining if the subject's blood
brain barrier is compromised comprises examining a level of MMP-9 from
the blood.

15. The method of claim 12, further comprising determining if the subject
is experiencing inflammation or is under oxidative stress.

16. A method of determining if a subject is experiencing prodromal
schizophrenia, the method comprising: determining if the subject has a
genetic susceptibility to schizophrenia; determining if the subject's
blood brain barrier is compromised; and reporting if the subject is
experiencing prodromal schizophrenia based on the concurrent presence of
a genetic susceptibility for schizophrenia and a weakened blood-brain
barrier.

17. The method of claim 16, wherein determining if a subject has a
polymorphisms in a gene associated with a glutamate receptor, or in gene
associated with an enzyme of the oxidative pathways related to
glutathione and neuregulin.

18. The method of claim 16, wherein determining if the subject's blood
brain barrier is compromised comprises determining the subject's
expression or level of one or more of: TNF, IL-1, IL-6, Haptoglobin,
MMP-9, S100B.

19. The method of claim 16, wherein determining if the subject's blood
brain barrier is compromised comprises examining a level of MMP-9 from
the blood.

20. The method of claim 16, further comprising using diffusion tensor
imaging to confirm the presence of prodromal schizophrenia.

21. A method of preforming diffusion tensor imaging (DTI) comprising:
taking a magnetic resonance image (MRI) of a subject's brain; computing
the orientation probability density function (PDF) at each voxel of the
MRI image using a Riemannian framework that does not require that the
orientation probability density function be represented by any fixed
parameterization, wherein a nonparametric representation of the
orientation PDFs is based upon a Riemannian manifold.

22. A method of treating a subject with prodromal schizophrenia, the
method comprising providing a subject experiencing prodromal
schizophrenia with a composition to improve, repair, or prevent further
damage to the blood-brain barrier.

23. A method of treating a subject with prodromal schizophrenia, the
method comprising providing a subject experiencing prodromal
schizophrenia with a composition to inhibit MMP-9.

24. The method of claim 20, further comprising determining if the subject
is prodromal for schizophrenia by obtaining diffusion tensor imaging to
probe the integrity of white matter and to refine such assessments by
incorporating geodesic distances based upon a Riemann manifold.

[0002] All publications and patent applications mentioned in this
specification are herein incorporated by reference in their entirety to
the same extent as if each individual publication or patent application
was specifically and individually indicated to be incorporated by
reference.

FIELD

[0003] The compounds and methods described herein related generally to the
treatment of neurodevelopmentally based disorders, and particularly the
treatment of prodromal schizophrenia.

BACKGROUND

[0004] Neuropsychiatric disorders such as schizophrenia are difficult to
diagnose early and difficult to treat. However, there is a strong
motivation to diagnose early, at preclinical or prodromal stages of the
disorder, since early intervention may blunt, reduce or even prevent the
full expression of this lifelong disease.

[0005] Because of current limitations in diagnosis, the prospective
diagnosis of subjects as being in a prodromal risk syndrome for psychosis
has yet to be accepted by psychiatric professional societies, the Food
and Drug Administration, or US insurance companies. The absence of
operational hallmarks of clinical validity has in turn slowed the
development of a treatment research evidence base that could benefit
these impaired, symptomatic, at-risk subjects and their families. One of
the most important questions is whether the prodromal diagnosis can be
refined so as to increase the proportion of cases that convert to
psychotic illness.

[0006] Currently proposed "Risk Syndrome for Psychosis" (RS) criteria are
derived from the Ultra High Risk criteria (UHR) and prodromal or Clinical
High Risk criteria (CHR), and consist of subthreshold or attenuated
positive psychotic symptoms. Identifying individuals meeting these
criteria affords the possibility of early intervention to prevent or
delay onset of full blown psychotic disorder. In particular, intervention
in the prodromal phase of schizophrenia and related psychoses may result
in attenuation, delay or even prevention of the onset of psychosis in
some individuals. However, a "prodrome" is difficult to recognize
prospectively because of its nonspecific symptoms.

[0007] Prodromic schizophrenia is often referred to as the onset phase of
schizophrenia. Detection of prodromal schizophrenia would be beneficial
because it could allow earlier and more specific treatment, which may
ultimately prove more effective. However, detection and treatment of
prodromal schizophrenia is difficult because there is no definitive test
for prodromal schizophrenia, which is typically present before the
subject starts actively hallucinating or exhibiting bizarre behavior
characteristic of schizophrenia. The prodrome phase usually occurs one to
two years before the onset of psychotic symptoms (for example:
hallucinations, paranoid delusions) in schizophrenia. The symptoms people
usually have during this time aren't very specific. Usually people report
symptoms of anxiety, social isolation, difficulty making choices, and
problems with concentration and attention. It is late in the prodromal
phase that the positive symptoms of schizophrenia begin to emerge.

[0008] Three kinds of prodromal subgroups have been described: attenuated
positive symptom syndrome; brief intermittent psychotic syndrome; and
genetic risk plus functional deterioration. The attenuated positive
symptom syndrome (APSS) classification is associated with problems with
communication, perception, and unusual thoughts that don't rise to the
level of psychosis. These symptoms have to occur at least once weekly for
at least one month and become progressively worse over the course of a
year. The brief intermittent psychotic syndrome (BIPS) prodrome subgroup
is associated with problems with communication and perception, and the
subject also experiences intermittent psychotic thoughts. The person
experiences bizarre beliefs or hallucinations for a few minutes daily for
at least one month, and for no more than three months. The last prodromal
subgroup is the genetic risk plus functional deterioration group (G/D);
these subjects are not currently psychotic but have been previously
diagnosed with schizotypal personality disorder or they have a parent,
sibling, or child that has been diagnosed with a psychotic disorder.
Subjects are considered part of this subgroup if in the past year they
have had substantial declines in work, school, relationships, or general
functionality in daily life.

[0009] Although subject's may seek psychiatric help during the prodrome
phase because of these disturbing symptoms, actual diagnosis of prodromal
schizophrenia has proven extremely difficult, if not impossible, because
these symptoms exist in many psychiatric and medical conditions. The
problem of accurate diagnosis and treatment is particularly difficult for
subjects who may be experiencing APSS or BIPSS prodromal schizophrenia.
Many people experiencing prodromal schizophrenia that may later develop
in to full-blown (late stage) schizophrenia) are misdiagnosed during the
prodrome phase.

[0010] Although some highly significant predictors of psychosis have been
found (e.g., long duration of prodromal symptoms, poor functioning at
intake, low-grade psychotic symptoms, depression and disorganization)
such behavioral predictors may be difficult to assess. The so-called SIPS
criteria for a prodromal syndrome emphasize onset or worsening in the
preceding 12 months of attenuated positive symptoms in one or more of
five possible categories: unusual thought-content, suspicion/paranoia,
perceptual anomalies, grandiosity, and disorganized communication. Such
risk factors may be combined with other risk factors including family
history, substance abuse, and ongoing mental state. Conclusively and
rapidly determining such risk factors has proven difficult, however.

[0011] We herein propose rapid screens or tests to confirm prodromal
schizophrenia that may be used to quickly and reliably determine that a
subject is likely in a prodromal schizophrenic state. Such a test may
evaluate a subject's genetic predisposition, including examining
candidate genes involved in the pathogenesis of schizophrenia As
discussed in greater detail below, the screening systems and methods
described herein may confirm or suggest prodromal schizophrenia when a
subject with a genetic susceptibility to schizophrenia experiences
inflammation resulting in a decrease in the efficacy of the blood-brain
barrier. We further disclose brain imaging modalities which may be
incorporated for diagnosis of such prodromal states as well.

[0012] The majority of pathogenic genes are positively up-regulated, in
part, via the action of the transcription factor NF-κB that plays
key roles in orchestrating inflammatory responses and cell fate
decisions. Other candidate genes in the pathogenesis of schizophrenia,
involve interactions between neuregulin (NRG1) and glutamate receptors.
The reported abnormalities in these receptor subtypes during brain
development likely involve abnormal signaling related to axonal
migration. The migrational defects in schizophrenia result in impaired
cortical-subcortical-hippocampal communication networks. While the
primary mechanisms involved in these migrational abnormalities are not
completely understood, it is currently proposed that epigenetic and
epistatic factors are critical to the emergence of these impairments.
These epigenetic factors may be understood as representing a pathological
cascade in which genetic abnormalities as disclosed increase
vulnerability to the developmental regression features found in
schizophrenia but require a "second hit" in order to reach clinical
significance and clinical manifestations of overt symptomatology. The
second hit relates to immunogenic factors and in many ways may be
regarded as a brain specific autoimmune disorder. Several lines of
evidence suggest that immunological factors contribute to schizophrenia.
Increased activity, C3, C4 complement components, in schizophrenia has
been reported as well as elevated plasma levels of sTNF-R1 and
haptoglobin.

[0013] We herein propose that the prodromal (pre-symptomatic) diagnosis
and treatment of psychosis or specifically schizophrenia may be
established by both the concurrent presence of both a susceptibility to
schizophrenia (e.g., as evidenced by a genetic polymorphism in one or
more genes typically in a neurodevelopmental pathway implicated in
schizophrenia) evidence of a pro-inflammatory condition that results in a
decrease in blood-brain barrier efficacy, and objective neuroimaging
parameters acquired through diffusion tensor imaging.

[0014] In addition, we herein describe therapies and treatments (including
therapeutic compounds and compositions) that may be specifically used to
treat prodromal schizophrenia, even in the absence of confirmation (e.g.,
by one of the tests or screens described herein). These compositions and
treatments may include compositions known to increase the efficacy of the
blood-brain barrier.

[0015] We further propose novel treatments directed at treating prodromal
schizophrenia which may include: (1) detection of genetic vulnerability;
(2) clinical confirmation by combining confirmatory serological
biomarkers indicative of a pro-inflammatory state (particularly
biomarkers indicating a decrease in blood-brain barrier efficacy), (3)
obtaining diffusion tensor imaging to probe the integrity of brain white
matter; and (4) basing treatment (even in the absence of full-fledged
symptoms) on the concurrent presence of a psychosis succeptability
marker, and/or a pro-inflammatory condition effecting the blood-brain
barrier. Treatment even in the absence of full-fledged symptoms may
therefore be based on treatment of the prodromal state alone, given a
reliable indication of prodromal schizophrenia.

[0016] As mentioned briefly above, a primary need in the field of
schizophrenia is the identification of etiologically significant
biomarkers. Such identification, especially in preclinical or prodromal
stages of these disorders, may provide a novel opportunity to reduce the
probability of the full expression of these conditions, which if left
untreated, almost invariably become chronic. It would clearly be
desirable to identify a diagnostic tool for schizophrenia that is highly
specific, and highly sensitive. However, in the absence of such a marker,
the identification of factors associated with a higher probability of
developing such a condition may be acceptable if the clinical response
possesses a significantly lower risk to a child than a conventional
medication. Of importance the marker should signify the disease early in
its course, as there is evidence that delays in diagnosis and
intervention lead to a poorer prognosis. In addition, a method that is
cost-effective and non-invasive would be of added value. Given that
subclinical or pre-clinical psychotic disorders may predict proneness,
intervention in at risk individuals holds the promise of better outcomes.
Thus, there is also a need for compositions, such as particularly medical
food and pharmaceutical compositions, which are effective for treatment
of psychosis such as schizophrenia in the prodromal state. It would be
useful to provide such compositions to at-risk subjects, where risk is
determined by one or more biomarkers indicating a susceptibility to such
neuropsychiatric disorders. Described herein are candidate biomarkers and
compositions (including medical foods and pharmaceutical compositions)
that may be used to treat or prevent prodromal schizophrenia.

SUMMARY OF THE DISCLOSURE

[0017] Described herein are systems, compositions, and methods of
identifying and/or treating psychosis, and particularly prodromal
schizophrenia. In particular, the methods, compositions and systems may
be used to detect and/or treat prodromal schizophrenia. Thus, at least
some of the systems described herein may therefore be referred to as
prodromal schizophrenia detection systems or a prodromal schizophrenia
treatment system; system may include diagnostics, kits, screens,
therapies, and the like. At least some of the compositions described
herein may be referred to as compositions for the treatment of
schizophrenia (or prodromal schizophrenia); compositions may include
medical foods, pharmaceuticals, and the like. The methods described
herein may include methods of detection prodromal schizophrenia, methods
of treatment of prodromal schizophrenia, and/or methods of detection and
treatment of prodromal schizophrenia.

[0018] For example, described herein are systems, compositions, and
methods for identifying individuals at risk for prodromal schizophrenia.
A method or therapy for treatment of prodromal psychosis (such as
schizophrenia) may include any of the following steps: identify a subject
at risk for psychosis based on early symptoms (e.g., memory loss, changes
in behavior, etc.); determine if the subject has a susceptibility to
psychosis by family history and/or screening for the presence of genetic
markers (e.g., single nucleotide polymorphisms) implicated as increasing
the risk of susceptibility to psychosis; determine if the subject is in
either (or both) a pro-inflammatory state and/or a state oxidative
stress, and particularly a state indicative of weakening of the
blood-brain barrier; indicating that the subject is in prodromal
psychotic state if the subject is both genetically susceptible and
experiencing a weakening of the blood-brain barrier (e.g., while in a
pro-inflammatory and/or oxidative stress state); and treating the subject
with a compound or composition (e.g., a compound containing N-acetyl
cysteine). In some variations the step of determining the susceptibility
and determining the pro-inflammatory state and/or oxidative stress
(and/or the status of the blood-brain barrier) may be advantageously
performed in the same assay.

[0019] The step of determining if a subject has a susceptibility to
schizophrenia may include screening for genetic markers (e.g.,
polymorphisms) linked to schizophrenia in a pathway that is implicated in
cell-signaling proteins that are involved in both brain development and
in the inflammatory cascade. Examples of such genetic markers are
described herein. The step of determining if the subject if a subject is
experiencing a weakening of the blood-brain barrier may include
determining if the subject is in either (or both) a pro-inflammatory
state and/or a state oxidative stress, and may also be performed as part
of the same screen as the genetic susceptibility mentioned above (e.g.,
using the same subject sample, or a concurrently taken sample), and may
include examining the subject sample for pro-inflammatory markers or
markers or oxidative stress, particularly those indicative of a
dysfunction of the blood-brain barrier. Examples of these markers are
described herein. In some variations, testing for pro-inflammatory
markers or markers or oxidative stress may be a test for cerebritis.

[0020] For example, in one variation, a panel for determining if a subject
is in a prodromal schizophrenic state (or at risk for being in such a
state) may be a panel to determine levels of TNF, IL-1, IL-6,
Haptoglobin, MMP-9 and S100B, or a sub-set of these.

[0021] A further step in confirmation comprises measuring the integrity of
white matter via utilization of diffusion tensor imaging. Limitations of
current diffusion tensor imaging are discussed and methods on how to
overcome these limitations in clinical settings are disclosed

[0022] Also described herein are reports that may accompany results of any
of the screens described herein, which may inform the physician of test
results as well as providing an interpretive guide, e.g., indicating the
likelihood of prodromal schizophrenia based on one or more additional
factors.

[0023] Thus, the methods and compositions described herein may relate in
general to a method of identifying phenotypical and genotypical
biomarkers in preclinical or prodromal stages of a pediatric
neuropsychiatric disorder and subsequently addressing the risk by
potentially inhibiting the clinical expression of said disorder through
the employment of a safe medical food compound.

[0024] As mentioned, also described herein are compounds for the treatment
of prodromal schizophrenic states. In some variations the compounds may
be compositions including low dose lithium, essential fatty acids and an
acetylcysteine compound (e.g., NAC). This composition or compound may be
particularly advantageous for the treatment of prodromal schizophrenia.
In some variations of the compounds for treatment of prodromal
schizophrenia are compounds that enhance the blood-brain barrier and/or
compounds that prevent damage to the blood-brain barrier. For example,
described herein are compounds including one or more inhibitor of MMP-9
to treat prodromal schizophrenia.

[0025] The fatty acid compounds described herein that may be part of the
compositions or compounds include essential fatty acids (EFAs), such as
alpha-linolenic acid (an omega-3 fatty acid) and linoleic acid (an
omega-6 fatty acid). Other fatty acids that may be used include
conditionally essential fatty acids, such as gamma-linolenic acid (an
omega-6 fatty acid), lauric acid (a saturated fatty acid), and
palmitoleic acid (a monounsaturated fatty acid).

[0026] This invention also provides a method for preventing or treating
prodromal schizophrenia in a subject comprising administering to the
subject a composition such as those described herein.

[0031] In general, the systems, compositions and methods described herein
may be used to diagnose and/or treat prodromal psychosis. Although the
examples described herein are specific to the diagnosis and treatment of
schizophrenia, other psychosis may be similarly diagnosed and/or treated.

[0032] In general, methods of determining if a subject is at risk for
developing schizophrenia may include (1) confirming that the subject is
experiencing symptoms consisted with prodromal schizophrenia; (2)
determining if the subject is susceptible to developing schizophrenia
based on a genetic susceptibility ("genetic susceptibility for
schizophrenia"); and (3) determining if the subject is under either (or
both) oxidative stress or a pro-inflammatory state ("current
oxidative/inflammation stress state") with a decrease in blood-brain
barrier (BBB) function and (4) applying novel diffusion tensor imaging
modalities to confirm diagnosis. Thus, described herein are systems, such
as screens or tests, which may determine at least some of these factors,
as well as reports for reporting and providing interpretive aid to the
results of these screens helpful for accurately and rapidly diagnosing
prodromal schizophrenia. The methods, systems and/or reports may also
help guide therapeutic decisions for treating a subject. The reports
described herein may include reports describing the prodromal status of
the subject by aggregating and indicating the susceptibility for
schizophrenia and the status of the subject's blood brain barrier and/or
inflammatory (and/or oxidative stress) state.

[0033] Compounds for treating a subject experiencing or at risk for
prodromal schizophrenia are also described in greater detail below. In
some variations, the compounds or compositions include one or more agents
for improving the function of the blood-brain barrier or preventing
damage to the blood-brain barrier. For example, in some variations the
compounds or compositions include one or more inhibitors of MMP-9, such
as minocycline. In some variations the compounds or compositions
generally include a formulation compound and an acetylcysteine compound,
combined with low dose lithium and essential fatty acids.

[0034] As mentioned, in some variations, these compounds are prescribed if
a test/screen/panel for prodromal schizophrenia (as described herein or
elsewhere) indicates a high likelihood of prodromal schizophrenia.
Alternatively, these compounds, and particularly the medical food
variations, may be prescribed or taken even in the absence of a
confirmation of prodromal schizophrenia. These compounds may also be used
to treat existing (as opposed to prodromal) schizophrenia. The compounds
and methods described herein may be configured as medical foods. The
formulation of these compounds, as well as the application or use of
these compounds as medical foods to treat subjects in need thereof is
described in greater detail below, including by example.

[0035] As used herein, a subject may be a patient, and may be any subject,
including humans.

[0036] As used herein the phrase "medical food" may refer to foods that
are formulated and intended for the dietary management of a disease or
disorder. These foods may provide distinctive nutritional elements that
cannot be met by normal diet alone. Medical foods may be distinct from
the broader category of foods for special dietary use and from
traditional foods that bear a health claim. A medical food may be a food
for oral ingestion or tube feeding (nasogastric tube), may be labeled for
the dietary management of a specific medical disorder, disease or
condition for which there are distinctive nutritional requirements, and
may be intended to be used under medical supervision. Examples of medical
foods may include: nutritionally complete formulas, nutritionally
incomplete formulas, and formulas for metabolic disorders. Although the
variations and examples described herein are specific to medical foods,
in some variations the compositions described herein may be prepared
and/or compounded as traditional "drugs" or medicaments.

Part I: Assessing Prodromal Schizophrenia

[0037] In general, a prodromal schizophrenic state may be assessed by
examining (1) subject behavioral characteristics associated with
prodromal schizophrenia; (2) genetic susceptibility to schizophrenia; and
(3) a weakening of the blood-brain barrier. In some variations the
etiology of the prodromal state may be examined by looking at both or
either the particular genetic factors providing susceptibility to
prodromal schizophrenia and the trigger state (e.g., the inflammatory
state and/or oxidative stress) which correlates with the prodromal
schizophrenia. If a patient is exhibiting characteristics consistent with
prodromal schizophrenia, and has a genetic susceptibility to
schizophrenia and is experiencing a decrease in blood-brain barrier
function, the subject is likely to be experiencing prodromal
schizophrenia, and appropriate treatment may be indicated. The treatment
indicated may be further refined based on the degree of behavioral
characteristics, the type, class or extent of genetic susceptibility, and
the etiology and/or extent of weakening of the blood-brain barrier.

[0038] Without being bound to a particular theory, the inventor has
hypothesized that prodromal schizophrenia may be triggered in a
particular individual when the individual has a genetic susceptibility
for schizophrenia and is "triggered" to enter the prodromal schizophrenic
state by an inflammatory response and/or an oxidative stress. This is
illustrated diagrammatically in FIG. 1A. In this example, genetic
susceptibility for schizophrenia may be a result of certain mutations or
dysfunctions of genes, typically genes that are implicated both in
neurodevelopment and the immune response, such as neuregulin. As
illustrated in FIG. 1A, when the subject having a genetic susceptibility
for schizophrenia is triggered by an inflammatory response (e.g.,
potentially due to infection, injury, or any other cause) and/or
oxidative stress, the result is a weakening of the blood-brain barrier,
which may result in decrease in the integrity of the blood-brain barrier
(e.g., partial breakdown). This decrease in function of the blood-brain
barrier in tern leads to prodromal schizophrenia, and may ultimately
progress into full-blown schizophrenia. Importantly, under this model
even prodromal schizophrenia (which is otherwise difficult to diagnose
and treat) may be detected with confidence, in subjects (1) having
behaviors consistent prodromal schizophrenia where the subject (2) has a
genetic susceptibility to schizophrenia and (3) has a weakened
blood-brain barrier, and in some variation, (4) acquiring tensor imaging
to interrogate the integrity of white matter in the brain Thus, if all or
most of these factors are present, the subject may be diagnosed and
treated for prodromal schizophrenia.

[0039] Further, under this model the weakening of the blood-brain barrier
is believed to be triggered in subjects with a genetic susceptibility
when a trigger stimulus (e.g., inflammation, oxidative stress, etc.) is
present. Thus, detection of inflammation and/or oxidative stress in the
subject (in addition to weakening of the blood-brain barrier) may
determine the etiology of the prodromal state, which may further refine
the proposed treatments. Alternatively, in some variations, detection of
the presence of inflammation and/or oxidative stress in the subject may
be used as a proxy for a determination of prodromal schizophrenia, when
factors (1) and (2) are also present (e.g., the non-specific symptoms
consistent with prodromal schizophrenia and a genetic predisposition to
schizophrenia). FIG. 1B outlines one application of the method of
diagnosing prodromal schizophrenia on the basis of the model described
above. This model (and theory) is elaborated in greater detail below. It
should be apparent to those of skill in the art that the methods, systems
and compounds/compositions for treating and diagnosing prodromal
schizophrenia described herein are not dependent on this model and
theory, and may function as claimed even in the event that the
theoretical framework is incomplete or even incorrect. Thus, the inventor
does not wish to be bound by the model and theory described herein.

[0040] The pro-inflammatory state associated with prodromal schizophrenic
states has been observed in a research context but has been previously
unrealized clinically. Despite theoretical causal associations, the
ability to diagnosis prodromal schizophrenia states clinically, based
upon recognition of biomarkers indicative of such a state, as well as the
implementation of specific anti-inflammatory agents prescribed to inhibit
the adverse effects of such, have not yet been realized. To the
inventor's knowledge, the pathological link between a pro-inflammatory
state in prodromal schizophrenia and alterations in the blood brain
bather has not been previously explored as either a diagnostic or
therapeutic target for prodromal schizophrenia.

[0041] The blood-brain barrier is a semi-permeable membrane composed of
endothelial cells connected by tight junctions. It functions as a
physiological barrier which dynamically regulates the exchange of
substances from the vascular system and brain. Increased permeability of
the blood brain barrier has been demonstrated in a variety of
neurological disorders including Alzheimer's, multiple sclerosis and
stroke but is less recognized as an association with schizophrenia or
other psychiatric states. The mechanisms related to blood brain barrier
alterations are varied but are linked to pro-inflammatory states and the
expression of cytokines and matrix metallic proteinases which increase
endothelial cell permeability.

[0042] Thus, the ability to identify abnormal changes in blood
brain-barrier permeability, primarily as a means to validate prodromal
schizophrenic states, but also as a means to identify other abnormal
psychiatric states associated with such changes, is critically needed as
an improvement in the field of clinical neuropsychiatric diagnosis.

[0043] Current methods to determine BBB breakdown are limited by cost
(contrast-enhanced MRI) or invasiveness (lumbar puncture). Neither is
suitable for broad-scale or frequent screening of populations at risk.
Thus, a surrogate marker of BBB function offers several advantages.
Various techniques to identify blood-brain barrier alterations are thus
herein described which can be applied specifically as an aide in
confirming the diagnosis of a pro-inflammatory state associated with
prodromal psychotic states such as schizophrenia. In some variations, the
method includes the use of an assay which includes biomarkers related to
pro-inflammatory cytokines, matrix metalloproteinaces, which may
specifically include MMP-9 and S100B.

[0044] S100B is believed to be a prevalent protein of the central nervous
system, and may be used as a peripheral biomarker for blood-brain barrier
disruption and often also a marker of brain injury. Studies have shown
that subjects suffering from depression or schizophrenia may have
immunological alterations that can be detected in the blood. Others
reported a possible link between inflammation, a microgliosis and the
blood-brain barrier (BBB) in suicidal subjects. Serum S100B may be used
as a marker of BBB function, and elevated levels of S100B may be regarded
as one indication of blood brain barrier disruption.

[0045] The MMPs are believed to have influence in several normal
processes, and the physiological and preanalytical factors affecting
these enzyme levels should be carefully identified in order to accurately
use these enzymes as psychiatric biomarkers; sample type has been found
to have an effect on the concentrations of metalloproteinases in
circulating blood. For example, sample type has been shown to have the
clearest effect on the levels of pro-MMP-9. Platelets contain both MMP-9
and TIMP-1, and it has been shown that platelet aggregation during
clotting can lead to increased release of MMP-9. It has also been shown
in several studies that serum has generally higher levels of MMP-9 than
do plasma samples. This has been documented using both ELISA and gelatin
zymography. For instance, coagulation activators had an effect on the
pro-MMP-9 serum levels, giving up to 4-fold MMP-9 levels in comparison
with native serum, probably due to platelet release of MMP-9. Since
pro-MMP-9 is sensitive to several preanalytical issues (e.g., coagulation
activators, anticoagulants, storage time), standardization is crucial if
this enzyme is to be measured from circulation. For example, MMP-9 levels
are affected by coagulation activation and the anticoagulant used, and
MMP-9 may therefore be more safely determinable in plasma samples.

[0046] Returning to FIG. 1B, a schematic example of an overall method of
determining the risk of prodromal schizophrenia is illustrated. In the
first step illustrated in FIG. 1B, the subject is assessed for behaviors
characteristic for prodromal schizophrenia 10. For example, behavioral
characteristics of prodromal schizophrenia may include neurotic symptoms,
mood-related symptoms, changes in volition, cognitive changes, physical
changes, behavioral changes and additional symptoms.

[0048] The initial prodromal symptoms in schizophrenia were studied in 100
DSM-diagnosed subjects and 100 controls. The median number of symptoms in
the subjects and the controls was 8 (range 2-13) and 0 (range 0-5),
respectively. Subjects developed symptoms indicating social,
occupational, and affective dysfunction, whereas the controls' symptoms
included magical content and disturbance in mood. There were significant
differences in the frequency of several symptoms appearing in the
subtypes. Initial prodromal symptoms were classified into negative,
positive-prepsychotic, and positive-disorganization categories. Subjects
with the disorganized subtype were more likely to have had negative
symptoms in the prodromal state, and subjects with the paranoid subtype
were more likely to have had positive symptoms in the prodromal state.
Observation of the course of symptoms from the prodromal to the psychotic
state revealed that 58 percent of the symptoms showed increased
intensity, 21 percent remained unchanged, 5 percent decreased, 3 percent
evolved into other affective difficulties, 9 percent progressed into
delusions, 1 percent progressed into hallucinations, and 3 percent
disappeared. The Global Assessment of Functioning Scale showed that
functioning is differentially affected among the subtypes even in the
prodromal phase. These findings provide a better understanding of the
initial prodromal state of schizophrenia, the signs and symptoms that
best define it, and their prognostic significance.

[0049] If the subject is positive for any of the behavior characteristics
consistent prodromal schizophrenia, such as those described above, the
subject may be prodromal (e.g., prodromal schizophrenic), however these
characteristics alone are not sufficient to make a determination, as they
are not specific to prodromal schizophrenia. As illustrated in FIG. 1B, a
method of diagnosing or analyzing prodromal schizophrenia may also
include the steps of determining if the subject also has a genetic
susceptibility to schizophrenia, and determining the likelihood that the
blood-brain barrier has been weakened.

[0050] In general, the step of determining a genetic susceptibility to
schizophrenia may include either or both a genetic screen of the subject,
looking at genes or genetic regions implicated in susceptibility for
schizophrenia (described in reference to Table 1 in greater detail
below), and/or examining the subject's own and family psychiatric
history. For example, an examination of the subjects own and family
psychiatric history may if the subject has been previously diagnosed with
schizotypal personality disorder, or they have a parent, sibling, or
child that has been diagnosed with a psychotic disorder; if so, the
subject may have a genetic susceptibility for schizophrenia. Since family
and personal psychiatric history may be difficult to determine and may
not be fully representative, at least some genetic screening to determine
or confirm genetic susceptibility may also be advised. As with the
non-specific behavioral characteristics, evidence of a genetic
predisposition (even in conjunction with the presence of behavioral
characteristics) is typically not sufficient to determine prodromal
schizophrenia. Thus, evidence that the blood-brain barrier has been
weakened (and/or evidence of inflammation/oxidative stress) may also be
necessary to conclusively determine prodromal schizophrenia.

[0051] Although the pathophysiology of schizophrenia remains unclear,
there is an increasing body of evidence that several molecular pathways
are involved. Neuroanatomical changes observed in psychotic disorders of
childhood suggest an active biological process during the transition to
full blown disease expression, raising the possibility that intervention
might be indicated prior to expression of frank psychotic symptoms.

[0052] Genes may include NRG1 and many of its downstream signaling
components (e.g., AKT1, etc.). For example, the NRG1α-induced
adhesion response is dependent on signaling through Akt pathways.
Perturbations in neuregulin-1 (NRG1)/ErbB4 function have been associated
with schizophrenia. Affected subjects exhibit altered levels of these
proteins and display hypofunction of glutamatergic synapses as well as
altered neuronal circuitry. ErbB4-mediated synapse maturation requires
its extracellular domain, whereas its tyrosine kinase activity is
dispensable for this process. Depletion of ErbB4 decreases the number of
primary neurites and stimulation of ErbB4 results in exuberant dendritic
arborization through activation of the tyrosine kinase domain of ErbB4
and the phosphoinositide 3-kinase pathway.

[0053] Nitration of NRG-Fs (nNRG-1) EGF-like domain results in an
inability to activate its receptor, Thus nitration of NRG-1's EGF-like
domain caused it to lose its ability to bind and activate its receptor
with loss of ligand-induced proliferation. The therapeutic effect of
inhibiting tyrosine nitration via the nitration inhibitor/thiol donor
N-acetylcysteine may restore Akt phosphorylation and subsequently restore
normal NRG development signals.

[0054] Recent evidence suggests that NRG1 may play a role in regulation of
inflammation and immune system response. Schizophrenia-associated
miss-sense mutations within the transmembrane region of NRG1 may also be
linked to immune dysregulation. In vivo, increased levels of 25
autoimmune markers as well as elevated levels of cytokines were
significantly associated with the NRG1 mutation. Increase in protein
secretion levels of IL-6, TNF-α, and IL-8 were also present in NRG
mutation carriers compared with controls.

[0055] Glutathione (GSH) is the major free radical scavenger in the brain.
Diminished GSH levels elevate cellular vulnerability towards oxidative
stress; characterized by accumulating reactive oxygen species. Levels of
reduced, oxidized, and total GSH were significantly decreased. Consistent
with the disclosure herein, accruing data suggest that oxidative stress
may be a critical factor underlying the pathophysiology of schizophrenia.
Post-mortem prefrontal cortex from subjects with each of these disorders
have found that the levels of reduced, oxidized, and total Glutathione
(GSH) were significantly decreased in all psychiatric conditions compared
to the control groups. Results suggested an enhanced generation of
reactive oxygen species and significantly lower free radical scavenging
capacity in schizophrenia subjects compared to healthy controls.

[0056] Indicators of oxidative stress are detectable in the urine and
blood of many schizophrenic subjects. Significantly increased levels of
isoprostanes were observed among schizophrenia subjects relative to the
controls, as measured by isoprostane-8-epi-prostaglandin F(2alpha)
(8-isoPGF(2alpha)) concentrations in the urine. In further support that
vulnerability to schizophrenia may be mediated by diminished brain
antioxidant systems, microarray studies demonstrate up-regulation of
SELENBP1 (selenium binding protein) in the brain and blood of subjects
with schizophrenia. Results demonstrate that SELENBP1 mRNA is unregulated
in schizophrenic brains versus controls and, in addition, that SELENBP1
gene expression is strongly positively correlated with presence of
psychosis across diagnoses. Furthermore, organic selenium compounds have
been demonstrated to significantly reduce apomorphine-induced stereotyped
behaviors in animals.

[0057] These lines of evidence point to the utility of raising antioxidant
brain defense systems to mitigate the risk of developing a childhood
psychotic disorder such as schizophrenia. In particular, glutathione
activity may be neuroprotective in these disorders by its influence on
receptor interactions within receptor heterodimers and receptor mosaics,
representing an important integrative mechanism for signaling based upon
redox sensitive mechanisms in brain networks.

[0058] Modulation of glutamatergic transmission through distinct and
selective receptor subtype mechanisms, such as potentiation of the
N-methyl-D-aspartate (NMDA) receptor glycine site, activation of group II
mGluR, and activation of glutamate-cystesine antiporters represent novel
neurochemical targets to treat schizophrenia. Thus, the potential ability
to positively modulate these receptors via the augmentation of brain
glutathione by administration of a specific medical food represents a
novel treatment.

[0059] The tripeptide glutathione (gamma-glutamylcysteinylglycine) is the
primary endogenous free radical scavenger in the brain. When glutathione
(GSH) levels are reduced there is increased cellular oxidative stress,
characterized by an increase and accruement of reactive oxygen species
(ROS). This may result in alterations in dopaminergic and glutamatergic
activity implicated in these illnesses. Glutamate and dopamine are highly
redox reactive molecules and produce free radicals during
neurotransmission. Neurons are thus at high risk for oxidative injury and
pro oxidative states have detrimental consequences on normal migrational
processes and brain connectivity during development.

[0060] Synthesis of glutathione, a major redox regulator, is compromised
in schizophrenia. The glutathione deficit, via its effect on
redox-sensitive proteins could contribute to dysfunction of
neurotransmitter systems in schizophrenia. Experimental models of
glutathione deficit changed the modulation of responses by dopamine, from
enhanced responses in control neurons (likely via D1-type receptors) to
decreased responses in low-glutathione neurons (via D2-type receptors).
This difference in dopamine modulation was due to a different modulation
of L-type calcium channels activated during NMDA stimulation: dopamine
enhanced function of these channels in control neurons but decreased it
in low-glutathione neurons. The effect of a glutathione deficit on
dopamine signaling was dependent on the redox-sensitive ryanodine
receptors (RyRs), whose function was enhanced in low-glutathione neurons.
This suggests that enhanced RyRs in low-glutathione neurons strengthens
intracellular calcium-dependent pathways following activation of D2-type
receptors and causes a decrease in function of L-type channels. This
represents a mechanism by which dopaminergic systems could be
dysfunctional under conditions of impaired glutathione synthesis as in
schizophrenia. These changes closely mimic the pathological imbalances of
dopamine signaling in schizophrenia, where D1 receptor function is
blunted and D2 receptor activity is exaggerated.

[0062] Genetic studies have shown an association between schizophrenia and
a GAG trinucleotide repeat (TNR) polymorphism in the catalytic subunit
(GCLC) of the glutamate cysteine ligase (GCL), the key enzyme for
glutathione (GSH) synthesis. This altered pattern potentially contributes
to the development of a biomarker profile useful for early diagnosis and
monitoring the effectiveness of novel treatments targeting redox
dysregulation in schizophrenia.

[0063] N-acetyl cysteine (NAC) is a precursor of cysteine and glutathione.
It has antioxidant properties, lipid stabilization, and preservation of
mitochondrial membrane potential, all of which may favorably impact
receptor function in neuropsychiatric states. Treatment of neurons with
lipid peroxidation byproducts results in a drastic reduction of
mitochondrial membrane potential, and this reduction is prevented by NAC.
This neuroprotective effect is due, at least in part, to preservation of
mitochondrial membrane potential and intracellular GSH levels. Thus, NAC
may exert neuroprotective effects via its ability to inhibit oxidation of
mitochondrial proteins, and stabilization of receptor membrane dimers.
Other variations or forms of NAC may be used; for example,
N-acetylcysteine amide (NACA).

[0064] NAC is also a potent glutamate modulator in the brain via its
effects on the glutamate/cystine antiporter. The glutamate/cystine
antiporter x(c)- transports cystine into cells in exchange for glutamate
at a ratio of 1:1. Glutamate exported by system x(c)- is largely
responsible for the extracellular glutamate concentration in the brain,
whereas the imported cystine is required for the synthesis of the major
endogenous antioxidant, glutathione. System x(c)- thus connects the
antioxidant defense with neurotransmission and behavior. Disturbances in
the function of system x(c)- have been implicated in nerve cell death due
to increased extracellular glutamate and reduced intracellular
glutathione. In vitro, inhibition of cystine import through system x(c)-
leads to cell death by a mechanism called oxidative glutamate toxicity,
which includes depletion of intracellular glutathione, activation of
12-lipoxygenase, accumulation of intracellular peroxides, and the
activation of a cyclic guanosine monophosphate (cGMP)-dependent calcium
channel towards the end of the death cascade. N-acetyl cysteine (NAC)
inhibits glutamate via the cystine-glutamate exchange system. Further, by
boosting glutathione, NAC acts as a potent antioxidant and has been shown
in two positive, large-scale randomized placebo-controlled trials to
affect negative symptoms in schizophrenia and depression in bipolar
disorder.

[0065] N-acetylcysteine (NAC) treatment may exert its effects by
activating cystine-glutamate exchange and thereby stimulating
extrasynaptic metabotropic glutamate receptors (mGluR). NAC treatment of
rats restored the ability to induce formation of new memories by
indirectly stimulating mGluR2/3 and mGluR5, respectively. Thus, a
previously undisclosed mechanism whereby NAC exerts beneficial effects in
cognitive decline in pediatric neuropsychiatric disorders involves the
facilitation of glutamate efflux and reduction of glutamate mediated
excitotoxicity. N-acetyl cysteine (NAC) as an add-on to maintenance
medication for the treatment of chronic schizophrenia has potential as a
safe and moderately effective augmentation strategy for chronic
schizophrenia. While the use of NAC has been proposed to be employed in
clinical states of schizophrenia, its application and use in prodromal
states and for the explicit purpose of preventing schizophrenia has not
been previously disclosed (see, e.g., H H Chen, A Stoker, and A Markou,
Psychopharmacology (Berl), 2010 May; 209(4):343-50).

[0066] The proposed mechanism linking oxidative stress with membrane lipid
abnormalities, inflammation, aberrant immune response, impaired energy
metabolism and excitotoxicity, leading to clinical symptoms and
pathogenesis of schizophrenia, suggests that interventions which restore
anti oxidant defense systems may reduce the vulnerability to the
expression of this disorder. Thus, described herein are methods of
treating prodromal (e.g., pre-clinical) schizophrenia with NAC and
particularly compositions containing NAC.

[0068] 700 mg of eicosapentaenoic acid (20:5n3), 480 mg of docosahexaenoic
acid (22:6n3) has been demonstrated to reduce the risk of progression to
psychotic disorder and may offer a safe and efficacious strategy for
indicated prevention in young people with sub-threshold psychotic states
or prodromal states

[0069] While each of these components; NAC, low dose lithium, and
essential fatty acids have been theoretically applied separately to
reduce the risk of progression from prodromal states to schizophrenia or
to ameliorate schizophrenic symptoms, the combination of these components
has not previously been disclosed

Additional Compounds for Treatment of Prodromal Schizophrenia

[0070] In general, a compound or composition for treatment of prodromal
schizophrenia may modulate the blood-brain barrier, and/or may inhibit
elements that weaken the blood-brain barrier. For example, in some
variations a composition or compound for treatment of prodromal
schizophrenia includes an inhibitor of MMP-9. MMP-9 inhibitors may
therefore reduce blood-brain barrier permeability and therefore be of
potential benefit in the treatment of prodromal schizophrenia may
include, for example: doxycycline and minocycline, valproic acid and
other HDAC inhibitors, lithium, NAC and Fish oils have been demonstrated
to improve the integrity of the blood brain barrier

[0071] For example, VPA (Valproic acid) significantly reduces elevation of
matrix metalloproteinase-9 (MMP-9), and prevents degradation of tight
junction proteins, and nuclear translocation of nuclear factor-κB
(NF-κB) and may be a neuroprotective agent

[0072] The amount of MMP-9 inhibitor to be used is typically sufficient to
reduce or inhibit MMP-9 activity or expression to restore or allow the
blood-brain barrier to be restored to normal permeability. Thus, in some
variations this amount may be determined based on clinical evidence or
trials examining the effect of the MMP-9 inhibitor on the blood-brain
barrier or directly on the characteristics behaviors associated with
prodromal schizophrenia.

[0073] An important element of the discovery relates to the critical
importance of maintaining adequate blood levels of the medical food or
drug composition. NAC, Lithium, essential fatty acids, minocycline and
Valproic acid all typically has a short half life; delayed-release
("slow-release") forms may therefore be used. After an oral dose of
N-acetylcysteine 200 to 400 mg has a terminal half-life of 6.25 h. Thus,
to achieve a therapeutic response in schizophrenia, an individual may
require frequent dosing. Therefore, an improvement in the application of
these compounds may involve a controlled delivery mechanism that would
ensure continuous blood levels to achieve a desired therapeutic response.

[0074] In some variations, methods for treating the subject may include
first determining if the subject is at risk for or is currently suffering
from prodromal schizophrenia.

Methods of Identifying Prodromal Schizophrenia

[0075] The methods described herein may include determining genetic
susceptibility for schizophrenia, determining if the blood-brain barrier
is weakened or damaged, and in some variations, determining if the
subject is under inflammation and/or oxidative stress (which may have led
to the weakening of the blood-brain barrier). Correlation of genetic
susceptibility with one or more direct measures of blood-brain barrier
status (and/or peripheral immune system and/or oxidative stress) may
allow diagnosis of prodromal schizophrenia at a level of certainty which
will mandate a treatment intervention in subjects expressing behaviors
consisted with prodromal schizophrenia.

[0076] Thus, in general the systems described herein may include a
screening panel incorporating both: (1) one or more indicators of genetic
susceptibility for schizophrenia; and (2) and one or more indicators of
blood-brain barrier function; in some variations the panel may also
include one or more indicators of an ongoing pro-inflammatory state
(e.g., inflammation such as cerebritis) or one or more indicators of
oxidative stress. (3) Obtaining diffusion tensor imaging for
confirmational diagnosis

[0077] An indicator of genetic susceptibility for schizophrenia may
include an indicator evidencing the presence of a genetic marker linked
to an elevated risk of schizophrenia. In particular, the marker may be
for one or more genes related to brain development signals (such as
neuregulin), which also may function in neuro-immune based pathways.
Example include ZNF804, MHC, DISCI, AKT, and specifically those
variations of these genes (e.g., Single Nucleotide Polymorphisms or SNPS)
suggesting heightened genetic vulnerability. Table 1, below illustrates
some of these genes.

[0078] For example, genetic markers for susceptibility to schizophrenia
may include gene polymorphisms in modulatory systems involving the
glutamate receptor (NMDAR), and enzymes of the oxidative pathways related
to glutathione and neuregulin. Thus, these genes may be examined to
determine the genetic susceptibility for schizophrenia; certain forms,
including certain polymorphisms, of these genes may be indicative of
positive or enhanced genetic susceptibility for schizophrenia. For
example, Altered neuregulin (NRG1) in brain development may be relevant
to the pathophysiology of schizophrenia and dysfunction of the NMDA
receptor. NRG1 normally acts to promote NMDA activity via the
phosphorylation of the NR2B subunit. Abnormal NRG1 signaling reduces NR2B
and subsequently impairs NMDA receptor function. Other genes (and
polymorphisms) are also described below for possible inclusion in
determining genetic susceptibility for schizophrenia.

[0079] In general, the markers that may be tested to determine genetic
susceptibility for schizophrenia are not limited to markers of genetic
polymorphisms. In general, any appropriate biomarker may be used.
Biomarkers may be in the form of genes, proteins and other molecules, or
phenotypical characteristics. Depending on the information they can
provide, biomarkers may be used in diagnostics as prediction tools (e.g.
subclinical markers, risk or vulnerability markers), or as diseases
signatures (e.g. disease markers, stage or progression markers). An
endophenotype may be neurophysiological, biochemical, endocrinological,
neuroanatomical, cognitive, neuropsychological or genetic.

[0080] The exemplary list of genetic markers (e.g., SNPs) indicating an
increased susceptibility to schizophrenia included above is not intended
to be exhaustive, but is illustrative. Additional genetic markers (not
limited to SNPs and not limited to the SNPs listed above in table 1) may
also be used. For example, another form of genetic variation known as
"runs of homozygosity" (ROH), whereby for relatively long stretches of a
subject's genome both chromosomes are identical, has been suggested as a
potential indicator of increased risk of schizophrenia.

[0081] A test for genetic susceptibility may include a plurality of
different markers, including any of those (e.g., all or a subset of
those) listed in Table 1, above. For example, the test or screen for
genetic susceptibility may include a sub-set of the markers listed above.
In some variations, the markers may be ranked or weighted, so that some
markers may have a greater indicative power (either alone or in
combination with one or more other, or adjunct) markers. For example,
markers may be weighted based on the strength of the correlation to
schizophrenia (e.g., full-blown DSM schizophrenia).

[0082] In some variations the test for genetic susceptibility may look at
protein expression rather than just genotype (e.g., proteomics). For
example, expression levels of proteins implicated in the brain
developmental and neuro-immune pathways, including any of those included
above in table 1, may be examined. Protein expression may be examined,
for example, by quantitative antibody screening, or any other appropriate
methods.

[0083] Any indicator reflecting the status of the blood-brain barrier may
be used. In particular the markers S100B and MMP-9 may be used as part of
an assay (including a serum-based assay). S100B is typically not found at
high concentration in the blood, but is found at higher concentrations in
brain (e.g., cerebrospinal) fluids. Thus if blood levels of S100B are
elevated, the blood-brain barrier may be weakened. Similarly, MMP-9 is an
enzyme that is known to weaken the blood-brain barrier when levels become
elevated. Thus, if MMP-9 serum levels are elevated, the blood-brain
barrier may be weekend. As described herein, the MMP-9 protein may be a
therapeutic target for the treatment of prodromal schizophrenia.

[0084] Any appropriate indicator of an ongoing (e.g., currently present)
pro-inflammatory state may be used as well. For example, markers of
active inflammatory process may include, but are not limited to,
measurements of complement, TNF alpha, IL-1,6,7,10, IFN gamma,
transferrin and haptoglobin via quantitative reverse PCR. In some
variations proteins such as soluble TNF-R1 (TNF alpha receptor-1) protein
may be assayed, as may levels of S100B, and/or MMP-9 (a non-specific
biomarker of increased blood brain barrier permeability). These soluble
proteins may provide an indication of inflammation, particularly in the
brain.

[0085] Table 2, below lists some of the markers and/or tests that may be
examined when determining if a subject is undergoing inflammation and/or
to determine the status of the blood-brain barrier. For example, matrix
metalloproteinases (MMPs) are suggested to play important roles in
autoimmune disease, chronic infections and recently in schizophrenia, and
may be examined to determine inflammation. The MMP level (e.g., MMP 9)
may be examined in comparison with a baseline value, or in comparison
with other markers. MMP-9, a member of the matrix metalloproteinase
family that degrades collagen IV and processes chemokines and cytokines,
participates in response to stress and injury. Up regulation allows
leukocytes to travel through lymphatics and may provide an indirect
marker of increased blood brain barrier permeability. TNF also induces
MMP-9, thus it may be an indirect marker for TNF increase. Levels and
activities of plasma MMP-9 can be investigated by enzyme-linked
immunosorbent assay and gel zymography. An MMP-9/TIMP-1 ratio can also be
calculated. A haptoglobin-MMP-9 Elisa may be a serological means to
measure. Normal values of MMP are expected in the range of 40 ng/m, while
salivary levels (e.g., levels in saliva) of MMP-9 are typically >20
ngmL, and TIMP-1>64 ngmL, thus inflammation may be apparent when the
MMP-9/TIMP-1 ratio is >1, in some variations.

TABLE-US-00002
TABLE 2
Markers that may be used to determine an inflammatory
state (including pro-inflammatory markers) associated
with prodromal schizophrenia
Marker Comments
TNF receptor (TNF alpha) Can measure from blood or other
bodily fluid by immunoassay
IL-1 Can be measured by immunoassays
(e.g., ELISA CLEA, other enzyme-
linked immunoassay, etc.)
IL-6 Can be measured by immunoassays
IL-7 Can be measured by immunoassays
IL-10 Can be measured by immunoassays
IFN gamma Can be measured by immunoassays
transferrin Can be measured by immunoassays
haptoglobin Can be measured by immunoassays
MMP-9 Can be measured by immunoassays
S100B Can be measured by immunoassays

[0086] Alternatively or additionally, any appropriate indicator of an
ongoing (e.g., currently present) indicator of oxidative stress may be
used. For example, direct or indirect measures of oxidative stress may be
used, such as measurements of cysteinylated or glutathionylated proteins
and other thiol compounds via liquid chromatography, mass spectrometry,
or redox based isotopes which can measure oxidation of specific cystines.
Tests or assays for TBARS (ThioBarbituric Acid Reactive Substances
Assay), urinary isoprostanes, etc., may be used.

[0087] In one example, an assay that may be used in helping to determine
if a subject is prodromal schizophrenic may include a sub-stet of the
markers reflecting the status of the blood-brain barrier and
inflammation. For example a screen for status of the blood-brain barrier
relevant to prodromal schizophrenia may include: TNF, Il-1, IL-6,
Haptoglobin, MMP-9, and S100B. In some variations this is a serological
panel. In some variations, the panel may be performed in conjunction with
a panel or panel examining the markers for genetic susceptibility
described above.

[0088] FIG. 2A illustrates one variation of a method of identifying
prodromal schizophrenia. The subject may be pre-screened by the physician
to determine that he/she is experiencing or exhibiting characteristics
consistent with prodromal schizophrenia such as those described above
(e.g., neurotic symptoms, mood-related symptoms, changes in volition,
cognitive changes, physical changes, behavioral changes and additional
symptoms). In FIG. 2A, the subject provides one or more subject samples
101. For example, the subject may provide a single sample (e.g., saliva,
blood, tissue, urine, etc.) or multiple samples. These samples may then
be examined, either separately or preferably in parallel, for both: (1)
one or more indicators of genetic susceptibility for schizophrenia 103;
and (2) and one or more indicators of the status of the blood-brain
barrier. In some variations, the sample is examined for an ongoing
inflammatory state 105 and/or one or more indicators of oxidative stress
107. The oxidative/inflammatory state(s) may be determined in addition or
in place of (as proxy for) determining the status of the blood-brain
barrier.

[0089] Screening the subject for both genetic susceptibility to
schizophrenia and the status of the subject's blood-brain barrier (and/or
ongoing inflammation/oxidative stress) may be performed as part of a
single kit or panel. For example, in some variations the system includes
a screen examining one or more genetic risk factors (e.g., all or a
subset of the SNPs listed in table 1, above) and a screen for markers
indicating status of the blood-brain barrier and/or either or both
inflammation (e.g., examining markers or correlates for inflammation, and
particularly inflammation of the subject's brain) and/or oxidative stress
(e.g., examining markers or correlates for oxidative stress, particularly
in the brain). In some variations a panel for confirming prodromal
schizophrenia may include only markers indicating the status of the
blood-brain barrier and/or inflammation/oxidative stress. For example,
when the subject has been predetermined to (1) exhibit behaviors
consistent with prodromal schizophrenia and (2) have a susceptibility to
schizophrenia (e.g., by personal or family history, or other genetic
screen).

[0090] A report of the results may be optimized to simplify the risk and
treatment of prodromal schizophrenia. The report may aggregate the
schizophrenia susceptibility risk with the elements considered to trigger
prodromal schizophrenia, such as inflammation and/or oxidative stress
and/or the status of the blood-brain barrier. Ultimately, the report may
provide an explicit indication of prodromal schizophrenia with one or
more metrics (e.g., the likelihood of prodromal schizophrenia, the
likelihood of susceptibility to schizophrenia, the presence or degree of
inflammation and/or oxidative stress, etc.). In some variations the
report may indicate which markers of susceptibility were examined, as
well as which indicators of the status of the blood-brain barrier and/or
inflammation and/or oxidative stress

[0091] Thus, described herein are reports providing an indication of a
subject's risk of prodromal schizophrenia. The report may include a
calibrated risk level. For example, the risk level may be provided as a
percentage (of a 100%), a numeric value (including a unit less score), a
qualitative score (e.g., "low, medium, high"), a population ranking
(e.g., indicating subject location on a population distribution), or the
like. The report may include a breakdown of the susceptibility and the
subject's inflammatory state and/or oxidative stress state. As with the
subject's prodromal schizophrenia state, any of these sub-elements
reported on the report (e.g., susceptibility,
inflammatory/pro-inflammatory state, oxidative stress state) may be
indicated with reference to a population (e.g., general population,
schizophrenic population, prodromal schizophrenic population, etc.), as
an absolute or relative ranking (numeric or quantitative, or
qualitative), or the like.

[0092] In determining the result to be reported on the report, the
subject's susceptibility may be combined with the subject's current
inflammation/oxidative stress state. Broadly speaking if the subject has
one or more markers linked to an increased susceptibility for
schizophrenia, and is also currently experiencing an elevation in
pro-inflammatory markers (e.g., inflammation) and/or is under oxidative
stress, then the subject is likely in a state of prodromal schizophrenia.
Specifically, if the subject is exhibiting behaviors consistent with
prodromal schizophrenia, has a genetic susceptibility to schizophrenia,
and has a weakened blood-brain barrier, the subject is likely prodromal
schizophrenic. The sensitivity of the test may be adjusted by adjusting
the ranking of susceptibility and/or the level of inflammation and/or
oxidative stress. The presence of one or more markers strongly correlated
with schizophrenia and/or multiple markers in any way (weakly, strongly,
etc.) correlated with schizophrenia may result in a higher likelihood of
genetic susceptibility for schizophrenia which may be combined with the
likelihood that the subject is experiencing a weakened blood-brain
barrier, and/or inflammation and/or oxidative stress.

[0093] Diffusion tensor imaging (DTI) may also be used to confirm or
assist in determining the presence or likelihood of a prodromal state.
For example, the intervention described herein may also include methods
of detection of a prodromal state including MRI Imaging modalities, such
as DTI. DTI can provide a probability estimate of a prodromal subject's
likelihood of developing schizophrenia using nonparametric density
estimator. White matter in the brain typically enables functional
networks to transmit signals to different regions of the brain through
axonal pathways. Diffusion weighted tensor imaging may provide a means to
reveal the human brain's connectivity by providing detailed quantitative
analysis of white matter in via in vivo measurement of passive diffusion
(random displacement) of water molecules. Information derived from
diffusion images can be used to infer the structural organization of
white matter. The mobility of water molecules is isotropic and its motion
is limited by the presence of tissue components such as cell membranes
and fibers. When those elements are aligned, the diffusion becomes
directionally preferential and thus anisotropic. In the white matter,
axons are organized in parallel bundles and water diffuses preferentially
in the direction of the axonal fibers. This anisotropic diffusion in the
white matter can be captured by diffusion-weighted images, and is
represented by a signal decrease due to diffusive motion in the direction
of the applied gradient field. In DTI, the local diffusion is related to
the strength of water diffusion along fiber orientation. At each image
voxel, diffusion is measured along a set of distinct gradients, producing
a corresponding signal. This can provide a Gaussian estimate of the fiber
orientation but may be inadequate in regions of crossings and branching
fibers, which is what is anatomically typical in the human brain.
Diffusion tensors do not follow multivariate Gaussian distributions.
Thus, a preferred method to overcome the limitations of DTI for use in
prodromal schizophrenia is herein disclosed.

[0094] This method computes the orientation probability density function
(PDF) at each voxel using a Riemannian framework which does not require
that the orientation probability density function be represented by any
fixed parameterization, such as a spherical harmonic expansion. Instead,
a nonparametric representation of the orientation PDFs which is based
upon a Riemannian manifold may be applied in this clinical setting. This
method may overcome the inherent non linearity of tensors which limits
their clinical applicability by incorporating measurements of geodesic
distances on the manifold of axonal pathways. The ability to apply such
measurements for use in diagnosing prodromal schizophrenia has not
previously been used.

[0095] In general, the reports described herein may be written,
electronic, oral, text messages, or the like. In particular, the reports
described herein may also include some analysis or interpretive guide for
understanding and acting upon the results.

[0096] As mentioned, if a subject is found likely to be experiencing
prodromal schizophrenia, the methods described herein may be used to
treat the subject. For example, the subject may be prescribed or given a
compound for the treatment of prodromal schizophrenia. For example, the
subject may be given a compound/composition for the treatment of
prodromal schizophrenia that improves the activity of the blood brain
barrier (e.g., making the blood-brain barrier less permeability,
restoring normal function, etc.). In some variations the
compound/composition is an inhibitor of MMP-9. In some variations, the
subject may be given a compound including: NAC, ascorbic acid, lithium
and essential fatty acids. Any of the compositors described herein may be
marked, labeled or packaged specifically and explicitly for use to treat
prodromal schizophrenia.

[0097]FIG. 2B illustrates one exemplary method of treating a subject,
which may include the steps of identifying the subject likely to have
prodromal schizophrenia, as described in FIG. 2A, and treating prodromal
schizophrenia when properly identified. For example, in FIG. 2B, the
first step 201 includes the identification a patient (i.e. subject, and
particularly a child or adolescent) at risk for schizophrenia. This may
be achieved by (1) examining the behavior of the subject to confirm that
he/she is experiencing behaviors consistent with prodromal schizophrenia
202, (2) examining biomarkers as just described that are indicative of
blood-brain barrier status 203. For example, endophenotypes may include,
for instance, subclinical psychotic symptoms including transient
psychosis, disorganization, etc. Biomarkers which reveal blood-brain
barrier status may also be, or be used in conjunction with, biomarkers
that increase oxidative stress and/or inflammation markers as described
in the paragraphs above. The subject is also either directly analyzed for
biomarkers indicative of genetic susceptibility to schizophrenia 205 or a
family/personal history indicative of a genetic susceptibility for
schizophrenia is completed.

[0098] Next, in subjects in which the biomarkers indicate both a
susceptibility of developing schizophrenia 207 and a dysfunction of the
blood brain barrier, (e.g., and/or an elevated state of inflammation
and/or oxidative stress 209). A diffusion tensor imaging study may be
subsequently employed to assess the integrity of white matter. Improved
methods of determining the integrity of axons are disclosed.

[0099] Based upon analysis of diagnosis, the subject may be prescribed
and/or administered a compound or composition configured to treat
prodromal schizophrenia as mentioned earlier.

[0100] While the compositions, methods of forming them, and methods for
using them, have been described in some detail here by way of
illustration and example, such illustration and example is for purposes
of clarity of understanding only. It will be readily apparent to those of
ordinary skill in the art in light of the teachings herein that certain
changes and modifications may be made thereto without departing from the
spirit and scope of the invention.

[0101] In particular, it should be readily apparent to those of skill in
the art that the methods and compounds for treating prodromal
schizophrenia may be used independently of the methods of determining if
a subject is positive for (or at risk for) prodromal schizophrenia. The
method and compounds for treating prodromal schizophrenia may be used to
treat even subjects for whom prodromal schizophrenia has been determined
using other methods than those described herein. Further the compounds
described herein may be used for other indications (particularly other
neurological disorders or psychosis) and are not limited to prodromal
schizophrenia.